The effect of novel coronavirus disease-2019 (COVID-19) on fibromyalgia syndrome - Clinical and Experimental ...
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The effect of novel coronavirus disease-2019 (COVID-19)
on fibromyalgia syndrome
F. Salaffi1, V. Giorgi2, S. Sirotti2, S. Bongiovanni2, S. Farah1, L. Bazzichi3, D. Marotto4,
F. Atzeni5, M. Rizzi6, A. Batticciotto7, G. Lombardi8, M. Galli9, P. Sarzi-Puttini2
1
Rheumatology Unit, Dept. of Clinical and ABSTRACT Introduction
Molecular Sciences, Università Politecnica Objective. Fibromyalgia syndrome Fibromyalgia syndrome (FM) is a com-
delle Marche, Ancona; 2Rheumatology Unit,
ASST Fatebenefratelli-Luigi Sacco (FM) is a complex disease that is mainly plex disease that is characterised by a
University Hospital, Milan; 3Rheumatology characterised by chronic widespread wide range of symptoms, particularly
Unit, Dept. of Clinical and Experimental pain, fatigue and sleep disturbances chronic widespread pain, fatigue and
Medicine, University of Pisa; 4Rheumatol- and may be precipitated or worsened sleep disturbances (1, 2). It is quite
ogy Unit, ATS Sardegna, P. Dettori Hospital,
Tempio Pausania; 5Rheumatology Unit,
by many stressors. The aim of this study common as its mean population prev-
Dept. of Clinical and Experimental Medicine, was to observe the behaviour of FM alence is 2.2% in Italy (3) and 2.7%
University of Messina; 6Respiratory Unit, symptoms during the course of corona- worldwide (4). Its complex symptoma-
L. Sacco University Hospital, ASST virus disease 2019 (COVID-19). tology and the associated substantial
Fatebenefratelli-Sacco, Milan, Italy;
7
Rheumatology Unit, Dept. of Internal
Methods. Patients who had been diag- disability not only lead to a poor health-
Medicine, ASST Settelaghi, Ospedale nosed as having FM for ≥3 months were re- related quality of life (5), but also a
Di Circolo - Fondazione Macchi, Varese; cruited between February and May 2020. considerable economic burden for na-
8
Laboratory of Experimental Biochemistry & The collected data were age, sex, educa- tional health systems (6, 7). Its patho-
Molecular Biology, IRCCS Istituto Ortopedico tional level and marital status; height and genesis remains largely obscure, and
Galeazzi, Milan, Italy, and Dept. of Athletics,
Strength and Conditioning, Poznań University weight; and the scores of the revised Fibro- no satisfactory medical treatment has
of Physical Education, Poznań, Poland; myalgia Impact Questionnaire (FIQR), the yet been found (8, 9). The symptoms
9
Dept. of Infectious Diseases, ASST- modified Fibromyalgia Assessment Status are rarely constant but usually fluctuate
Fatebene-fratelli-Luigi Sacco University 2019 (FASmod), and the Polysymptomatic between a “FM” and a “non-FM” state
Hospital, Dept. of Biochemical and Clinical
Sciences L. Sacco, University of Milan, Italy. Distress Scale (PDS). The patients were (10), thus underlining the importance of
Fausto Salaffi, MD, PhD divided into those with or without concomi- aggravating and alleviating factors: for
Valeria Giorgi, MD tant COVID-19 infection. example, symptoms may be improved
Silvia Sirotti, MD Results. Eight hundred and ninety-seven by moderate physical activity (11, 12),
Sara Bongiovanni, PhD (93%) of the 965 patients (881 women or worsened by physical or mental
Sonia Farah, EngD
Laura Bazzichi, MD
[91.3%] and 84 men [8.7%]) were fol- stressors such as, physical hyperactivity
Daniela Marotto, MD lowed up on an outpatient basis because or physical trauma (13). Patients often
Fabiola Atzeni, MD, PhD of FM and 68 (7.0%) were either fol- associate stressors with the onset and
Maurizio Rizzi, MD lowed up as out-patients or hospital- exacerbations of the syndrome (14),
Alberto Batticciotto, MD
ised because of COVID-19. There was which have also been found to be sig-
Giovanni Lombardi, PhD
Massimo Galli, MD no difference in the sociodemographic nificantly associated with traumas and
Piercarlo Sarzi-Puttini, MD data of the two groups, but there were abuse (15-17). Furthermore, mainly on
Please address correspondence to: statistically significant between-group the basis of retrospective studies, it has
Valeria Giorgi, differences in the results of the clinimet- been hypothesised that infections may
Rheumatology Unit, ric tests. The major differences between precipitate the onset of FM (18).
ASST-Fatebenefratelli L. Sacco
University Hospital, the score of the items (those with the The novel Coronavirus disease-2019
Via G.B. Grassi 74, greatest disease impact) were the fol- (COVID-19) pandemic is currently at-
20157 Milano, Italy. lowing related symptoms: sleep qual- tracting the attention of most health
E-mail: vale.gio@fastwebnet.it ity (FIQR15), fatigue/energy (FIQR13), authorities and the general public, and
Received on September 17, 2020; accepted pain (FIQR12), stiffness (FIQR14). many FM patients are particularly
in revised form on November 2, 2020.
Conclusion. The mean total and sub- worried about their health particularly
Clin Exp Rheumatol 2021; 39 (Suppl. 130):
domain scores of all the tests were sig- because the clinical manifestations of
S72-S77.
nificantly higher in the patients with COVID-19 include flu-like symptoms
© Copyright Clinical and
Experimental Rheumatology 2021. COVID-19, which suggests that global such as asthenia, myalgia, headache
FM symptoms are more severe in pa- and diarrhoea that can mimic or aggra-
Key words: fibromyalgia, novel tients with infection. Further studies of vate FM (19).
coronavirus disease 2019 (COVID-19), the post-COVID19 patients are being The aim of this study was to evalu-
clinimetric scales, outcomes carried out in order to discover whether ate the behaviour of FM symptoms in
the worsened symptomatology continues patients with a confirmed diagnosis of
Competing interests: none declared. because of their hypersensitised state. COVID-19 by means of disease-spe-
S-72 Clinical and Experimental Rheumatology 2021The effect of COVID-19 on fibromyalgia / F. Salaffi et al.
cific questionnaires. An observational Table I. Educational level and marital status in FM patients with or without concomitant
study of this type may be of interest COVID-19 infection.
because of the high local burden of the FM FM+COVID19 Total score
disease (Italian Department of Civil
Defence [Dipartimento della Protezi- Education n n n (%)
one Civile], 2020) and the high level of Primary school 61 5 66 (6.8)
Secondary school 237 13 250 (25,9)
morbidity associated with it.
High school 451 49 500 (51.8)
University 148 1 149 (15.4)
Materials and methods
Marital status
Patient recruitment Single 153 12 165 (17.1)
Patients who had been diagnosed as Married 656 54 710 (73.6)
having FM for ≥3 months on the basis Divorced 75 2 77 (8.0)
of the 1990 American College of Rheu- Widow 13 0 13 (1.3)
matology (ACR) classification criteria
(20) or the modified 2010/2011 ACR and cold temperatures. The total version 19.0.1.0 (MedCalc Software,
criteria (21) were enrolled as in- or FIQR score is the sum of the three Mariakerke, Belgium). The continu-
out-patients at ASST Fatebenefratelli adjusted scores. ous data are presented as mean values
“L. Sacco” University Hospital, Milan, • The Widespread Pain Index (WPI) and standard deviations (SDs) or me-
and C. Urbani Hospital, Jesi (Ancona) was used in the 2010/2011 ACR FM dian values and interquartile ranges
between February and May 2020. The diagnostic criteria. It is based on the (IQRs) depending on their distribution,
patients with COVID-19 confirmed by patient’s perception of the painful- which was tested using the Kolmogo-
means of a nasopharyngeal swab were ness of 19 body regions in the previ- rov–Smirnov test. The patients were
recruited as in- or outpatients during a ous seven days (23). divided into those with or without con-
regular outpatient follow-up visit. • The Symptom Severity Scale (SSS) comitant COVID-19 infection. The χ2
All procedures performed in this study used in the 2010/2011 ACR FM test was used to compare the categori-
were in accordance with the ethical diagnostic criteria is based on esti- cal variables, and the Mann-Whitney U
standards of the Institutional Reviews mates of the severity of three symp- test was used to compare the continu-
Board of Ospedale C. Urbani and ASST toms (fatigue, unrefreshing sleep, ous variables. Spydergrams were used
Fatebenefratelli “Luigi Sacco” Univer- and cognitive symptoms) in the pre- to compare the FIQ-R and WPI sub-
sity Hospital and with the 1964 Hel- vious seven days, plus the presence domains (27). A p-value ofThe effect of COVID-19 on fibromyalgia / F. Salaffi et al.
Fig. 1. Box and whisker plots of: (A) FIQR, (B) PDS and (C) FASmod values (y-axis) for total score and each subscale scores (x-axis) in FM patients with
or without concomitant COVID-19 infection. The boxes represent the FIQR values from 25th to 75th percentiles. The middle lines inside boxes are the medi-
ans. The highest and lowest values are the maximum and the minimum data recorded. Mann-Whitney U test was used to compare FIQR scores.
Table II. FIQR, FASmod and PDS mean (SD) and median (25-75 percentiles) values for total score and each subscale scores.
FM FM+COVID19
Mean Median SD 25 - 75 P Mean Median SD 25 - 75 P p
FIQR overall_impact 9.49 9.00 6.24 3.00-15.00 12.76 14.00 4.31 10.00-16.00The effect of COVID-19 on fibromyalgia / F. Salaffi et al.
Item Item Description FM FM+COVID19
Score SD Score SD
FIQR-1 Brush or comb hair 2.69 3.17 5.13 2.73
FIQR-2 Walk continuously for 20 min. 4.19 3.49 6.77 2.44
FIQR-3 Prepare a homemade meal 3.56 3.17 5.70 2.39
FIQR-4 Vacuum, scrup, or sweep floors 5.49 3.25 7.32 1.89
FIQR-5 Lift and carry a bag full of groceries 5.83 3.44 6.95 2.35
FIQR-6 Climb one flight of stairs 4.26 3.21 5.76 2.59
FIQR-7 Change bed sheets 5.09 3.29 8.19 8.43
FIQR-8 Sit in a chair for 45 min 5.18 3.28 7.11 1.98
FIQR-9 Go shopping for groceries 4.53 3.41 6.66 1.98
FIQR-10 Cannot achieve goals 4.69 3.20 6.32 2.35
FIQR-11 Feel overwhelmed 4.81 3.31 6.44 2.51
FIQR-12 Pain rating 5.89 3.07 7.72 1.02
FIQR-13 Fatigue rating 6.19 3.15 8.60 1.64
FIQR-14 Stiffness rating 5.74 2.99 7.97 1.44
FIQR-15 Sleep quality 6.15 3.16 8.69 1.36
FIQR-16 Depression level 4.26 3.26 6.98 2.11
Fig. 2. Polar plot (spydergrams) of mean FIQR single item FIQR-17 Memory problems 4.57 3.10 6.79 1.94
scores for FM patients with or without concomitant COVID-19
FIQR-18 Anxiety level 4.98 3.15 7.20 2.45
infection (all at p-valueThe effect of COVID-19 on fibromyalgia / F. Salaffi et al.
FM patients, also in its subthreshold ments for the collaboration in data long traumatic events and mental disorders
in fibromyalgia syndrome: a comparison of
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